Datapoint: BCBS Minnesota to Cover Insulin at No Cost

September 4, 2019

Blue Cross and Blue Shield of Minnesota will cover insulin with no member cost-sharing in the 2020 plan year, according to a press release from the insurer. The new benefit applies to most of the insurer’s risk-based commercial risk plans (excluding some large employer groups). Blue Cross currently enrolls 32,064 individual and family plan members, 87,470 small group members and 229,927 large group members.

Blue Cross and Blue Shield of Minnesota will cover insulin with no member cost-sharing in the 2020 plan year, according to a press release from the insurer. The new benefit applies to most of the insurer’s risk-based commercial risk plans (excluding some large employer groups). Blue Cross currently enrolls 32,064 individual and family plan members, 87,470 small group members and 229,927 large group members.

Pill Club, CVS Dispute Raises Larger Questions

September 4, 2019

CVS Health Corp.’s Caremark division came under fire recently when Pill Club, a birth-control-delivery startup, accused the PBM of restricting access to contraceptives amid a reimbursement dispute. The dustup even spilled onto social media, with the hashtags #CVSDeniesCare and #BoycottCVS trending on Twitter on Aug. 15.

While the dust has since settled, experts tell AIS Health that the incident raises bigger questions, including whether social media will increasingly be used by smaller fish in the pharmacy supply chain to amplify their negotiating clout with powerful PBMs.

By Leslie Small

CVS Health Corp.’s Caremark division came under fire recently when Pill Club, a birth-control-delivery startup, accused the PBM of restricting access to contraceptives amid a reimbursement dispute. The dustup even spilled onto social media, with the hashtags #CVSDeniesCare and #BoycottCVS trending on Twitter on Aug. 15.

While the dust has since settled, experts tell AIS Health that the incident raises bigger questions, including whether social media will increasingly be used by smaller fish in the pharmacy supply chain to amplify their negotiating clout with powerful PBMs.

The situation started when the PBM notified Pill Club and other non-traditional pharmacies that had been receiving reimbursements at the same rate as retail pharmacies that they would be subject to different terms, a CVS spokesperson told AIS Health.

Pill Club responded by calling out the company on a section of its website, which said that “CVS Caremark’s proposed payment changes threaten Pill Club’s ability to serve members.” CVS, in turn, created a section on its own website to dispute Pill Club’s claims, writing that it is “irresponsible for The Pill Club to falsely suggest access to women’s health care is being jeopardized just so it can maximize its profits at the expense of our PBM clients.”

Mariana Socal, M.D., assistant scientist at the Johns Hopkins Bloomberg School of Public Health’s Department of Health Policy and Management, says Pill Club was “trying to harness the power from social media and public interest” in order to boost its negotiation capabilities with CVS. “I believe that that’s an important resource that we may see more and more being tapped into by perhaps these online retailers and others,” she adds.

Datapoint: Priority Health, Total Health Care to Merge

September 3, 2019

Priority Health and Total Health Care, Inc. said Aug. 29 that they plan to merge. The two Michigan-based health maintenance organizations would cover 174,186 medical lives, if the deal is approved by state regulators. A total of 1,761,033 recipients are currently enrolled in Medicaid HMO plans in Michigan.

Priority Health and Total Health Care, Inc. said Aug. 29 that they plan to merge. The two Michigan-based health maintenance organizations would cover 174,186 medical lives, if the deal is approved by state regulators. A total of 1,761,033 recipients are currently enrolled in Medicaid HMO plans in Michigan.

Many Life/Health Insurers Aim to Increase Staff in 2019

August 30, 2019

More than 85% of life/health insurers are looking to boost their staff over the next 12 months, according to the latest insurance labor market study by The Jacobson Group, a Chicago-based insurance executive search firm, and the Ward Group, a part of Aon plc. While 61% of insurers said in July 2018 that they intended to increase their staffing, 69% actually did so within the year. Over the next year, about 92% of life/health companies expect an increase in revenue, mainly driven by growth in market share.

by Jinghong Chen

More than 85% of life/health insurers are looking to boost their staff over the next 12 months, according to the latest insurance labor market study by The Jacobson Group, a Chicago-based insurance executive search firm, and the Ward Group, a part of Aon plc. While 61% of insurers said in July 2018 that they intended to increase their staffing, 69% actually did so within the year. Over the next year, about 92% of life/health companies expect an increase in revenue, mainly driven by growth in market share. The study also projects a 2.27% increase in life/health insurance industry employment during the next 12 months, if the industry follows through on its plans.

Recent reports suggest Cigna Corp. is considering selling its life insurance and group disability products, which currently cover about 15.4 million people according to the insurer’s second-quarter 2019 financial statements. The move would allow the company to focus more on its health insurance business. Cigna currently enrolls 16,400,235 people in its health insurance products, with 82.9% covered through an administrative services only (ASO) contracting arrangement.

Recent reports suggest Cigna Corp. is considering selling its life insurance and group disability products, which currently cover about 15.4 million people according to the insurer’s second-quarter 2019 financial statements. The move would allow the company to focus more on its health insurance business. Cigna currently enrolls 16,400,235 people in its health insurance products, with 82.9% covered through an administrative services only (ASO) contracting arrangement.

According to the National Health Care Anti-Fraud Association, health insurers lose more than $10 billion each year to health care fraud, waste and abuse. And according to experts, while strides have been made in combatting fraud, there is always going to be some new product ripe for fraud, along with the targets that have been around for years.

Melissa Jampol, an attorney with Epstein Becker Green and former assistant U.S. attorney, tells AIS Health that “insurers need to stay one step ahead of the trends.” She is a big proponent of data analytics, contending that robust analytics help insurers analyze prepayment claims and audit results, trying to prevent fraud before it happens and catch it after the fact.

By Barbra Golub

According to the National Health Care Anti-Fraud Association, health insurers lose more than $10 billion each year to health care fraud, waste and abuse. And according to experts, while strides have been made in combatting fraud, there is always going to be some new product ripe for fraud, along with the targets that have been around for years.

Melissa Jampol, an attorney with Epstein Becker Green and former assistant U.S. attorney, tells AIS Health that “insurers need to stay one step ahead of the trends.” She is a big proponent of data analytics, contending that robust analytics help insurers analyze prepayment claims and audit results, trying to prevent fraud before it happens and catch it after the fact.

Jampol says that opioid use and abuse is still a hot issue. Other targets of health care fraud she sees are telemedicine and durable medical equipment.

Jo-Ellen Abou Nader, vice president of fraud, waste, and abuse and supply chain optimization at Prime Therapeutics LLC, says last year the PBM launched a new data analytics platform to help identify and weed out fraud, waste and abuse.

She adds that “fraud is an evolution.” While health plans are still seeing the same opioid fraud schemes, there are also new schemes trending due to increased access to technology. For example, technology allows fraudulent companies to have more access to patients who don’t have the ability to see a caregiver in person.

Highmark Inc. has also seen a rise in telemedicine schemes involving compounded pain creams. The insurer is combating this type of fraud by identifying large spikes in certain drugs prescribed, says Kurt Spear, vice president of financial investigations and provider review at Highmark. “We can flag those claims, put a stop on them, and do an investigation,” he adds.